A multicentre case series of analytically confirmed gamma-hydroxybutyrate intoxications in Western Australian emergency departments: Pre-hospital circumstances, co-detections and clinical outcomes

INTRODUCTION

Gamma-hydroxybutyrate (GHB) use is associated with high risk of accidental overdose. This study examined the pre-hospital circumstances, demographic characteristics and clinical outcomes of analytically confirmed GHB emergency department (ED) presentations in Western Australia (WA).

METHODS

This case series was conducted across three WA EDs involved in the Emerging Drugs Network of Australia, from April 2020 to July 2022. Patient demographics, pre-hospital drug exposure circumstances and ED presentation and outcome characteristics were collected from ambulance and hospital medical records of GHB-confirmed cases.

RESULTS

GHB was detected in 45 ED presentations. The median age was 34 years and 53.3% (n = 24) were female. Most patients arrived at the ED by ambulance (n = 37, 85.7%) and required immediate emergency care (Australasian Triage Score 1 or 2 = 97.8%). One-third of patients were admitted to intensive care (n = 14, 31.1%). Methylamphetamine was co-detected in 37 (82.2%) GHB-confirmed cases. Reduced conscious state was indicated by first recorded Glasgow Coma Scale of ≤8 (n = 29, 64.4%) and observations of patients becoming, or being found, 'unresponsive' and 'unconscious' in various pre-hospital settings (n = 28, 62.2%). 'Agitated' and/or 'erratic' mental state and behavioural observations were recorded in 20 (44.4%) cases.

DISCUSSION AND CONCLUSIONS

Analytically verified data from ED presentations with acute toxicity provides an objective information source on drug use trends and emerging public health threats. In our study, patients presenting to WA EDs with GHB intoxication were acutely unwell, often requiring intensive care treatment. The unexpectedly high proportion of female GHB intoxications and methylamphetamine co-ingestion warrants further exploration.

Illicit drugs in the emergency department: Can we determine on clinical grounds if patients are intoxicated? Results from the Western Australian Illicit Substance Evaluation (WISE) study

INTRODUCTION

Presentations related to illicit drugs are a feature of emergency department practice. Clinicians may form a belief that a patient is intoxicated with illicit drugs based on patient self-report, clinical features on presentation and the local prevalence of illicit drug use. But evidence of the accuracy of this assessment is lacking. The Western Australian Illicit Substance Evaluation (WISE) study enrolled patients believed by their treating clinician to be intoxicated with illicit drugs, and this analysis aims to evaluate the validity of this belief.

METHODS

A blood sample was taken on patient arrival and details of patient history, examination and interventions were collected by clinical and research staff. Toxicological examination of biological samples used liquid chromatography-mass spectrometry techniques including Quadrupole Time of Flight screening and Triple Quadrupole targeted analyses.

RESULTS

Of 632 study presentations, 518 had illicit drugs detected representing a positive predictive value of 0.82 (95% confidence interval 78.7, 84.9). Those with illicit drugs detected were significantly less likely to arrive by police transport (p = 0.010) or to have used alcohol (p < 0.001). They were significantly more likely to report illicit drug use (p < 0.001) and a much smaller proportion were admitted to a psychiatric ward (3.5% vs. 19.3%, p < 0.0001). Heart rate and systolic blood pressure were significantly higher in the illicit drug group (p = 0.004 and p = 0.003).

DISCUSSION AND CONCLUSIONS

In this study, the positive predictive value of clinicians determining if their patient had taken illicit drugs was 0.82. Contemporaneous biochemical analysis in the clinical setting would increase this accuracy and inform patient care.

Detection of intact insulin analogues in post-mortem vitreous humour-Application to forensic toxicology casework

The application of proteomic techniques to forensic science widens the range of analytical capabilities available to forensic laboratories when answering complex toxicology problems. Currently, these techniques are underutilised in post-mortem toxicology because of the historic focus on smaller (<1,000 amu) drug molecules. Definitive confirmation of an insulin overdose by analysis of post-mortem biological matrices is rare and challenging, however can assist coronial investigations pertaining to accidental or intentional overdoses in both diabetic and nondiabetic populations. A semiautomated micro-solid phase extraction paired with mass spectrometry-based insulin methodology was developed and validated for routine use in a Forensic Coronial Toxicology Laboratory. This resulting work reports the first Australian cases where synthetic insulins were confirmed by mass spectrometry in the vitreous humour of Type 1 diabetics who intentionally or accidentally overdosed on their prescription medication glargine and aspart. The detection of glargine M1 in Case 1, aspart in Case 2 and glargine M1 was indicated in Case 3. This paper highlights advancements in forensic coronial toxicology and the promising potential of proteomic analysis in a forensic context.

Comparison of different techniques for in microgravity-a simple mathematic estimation of cardiopulmonary resuscitation quality for space environment

BACKGROUND

Since astronauts are selected carefully, are usually young, and are intensively observed before and during training, relevant medical problems are rare. Nevertheless, there is a certain risk for a cardiac arrest in space requiring cardiopulmonary resuscitation (CPR). Up to now, there are 5 known techniques to perform CPR in microgravity. The aim of the present study was to analyze different techniques for CPR during microgravity about quality of CPR.

MATERIAL AND METHODS

To identify relevant publications on CPR quality in microgravity, a systematic analysis with defined searching criteria was performed in the PubMed database (http://www.pubmed.com). For analysis, the keywords ("reanimation" or "CPR" or "resuscitation") and ("space" or "microgravity" or "weightlessness") and the specific names of the techniques ("Standard-technique" or "Straddling-manoeuvre" or "Reverse-bear-hug-technique" or "Evetts-Russomano-technique" or "Hand-stand-technique") were used. To compare quality and effectiveness of different techniques, we used the compression product (CP), a mathematical estimation for cardiac output.

RESULTS

Using the predefined keywords for literature search, 4 different publications were identified (parabolic flight or under simulated conditions on earth) dealing with CPR efforts in microgravity and giving specific numbers. No study was performed under real-space conditions. Regarding compression depth, the handstand (HS) technique as well as the reverse bear hug (RBH) technique met parameters of the guidelines for CPR in 1G environments best (HS ratio, 0.91 ± 0.07; RBH ratio, 0.82 ± 0.13). Concerning compression rate, 4 of 5 techniques reached the required compression rate (ratio: HS, 1.08 ± 0.11; Evetts-Russomano [ER], 1.01 ± 0.06; standard side straddle, 1.00 ± 0.03; and straddling maneuver, 1.03 ± 0.12). The RBH method did not meet the required criteria (0.89 ± 0.09). The HS method showed the highest cardiac output (69.3% above the required CP), followed by the ER technique (33.0% above the required CP).

CONCLUSIONS

Concerning CPR quality, the HS seems to be most effective to treat a cardiac arrest. In some environmental conditions where this technique cannot be used, the ER technique is a good alternative because CPR quality is only slightly lower.

A STUDY OF HUMAN SKIN GRAFTED UPON THE CHORIO-ALLANTOIS OF CHICK EMBRYOS

Human skin grafted upon the chorio-allantoic membrane of chick embryos adheres and becomes nourished for as long as 10 days. Occasionally regrafts upon a second egg have succeeded and thus prolonged the vitality of the graft to 14 days. In successful experiments the epithelium of the chorio-allantois fuses with that of the graft, the collagen fibers of the corium interlace with those of the membrane after the separation or disappearance of the ectodermal layer, and the blood vessels of the chick anastomose, and unite by intervening pools of extravasated blood, with those of the graft. This vascular communication between the two tissues is largely responsible for the nourishment of the graft by affording a plasmatic circulation. Gradually there is a partial revascularization of the graft by an ingrowth of blood vessels from the chick membrane. Human skin grafts were susceptible to experimental infection by several viruses.

Mixed feelings: satisfaction and disillusionment among Australian GPs

BACKGROUND AND AIMS

Medical practitioners' satisfaction with their work impacts on quality of care for their patients and on their own sense of fulfillment. Reforms introduced in the early 1990s into Australian general practice have led to concerns over the morale of GPs. This study examines satisfaction and dissatisfaction of GPs with regard to the reform strategy.

METHOD

GPs throughout Australia were approached via a popular GP magazine to express their views in a questionnaire comprising closed-end and open-ended questions enquiring about satisfaction with their current role and sources of satisfaction (and dissatisfaction) of working in general practice. Factor analysis was used to identify different sources of satisfaction (and dissatisfaction), which were intercorrelated and which together represented underlying factors. Logistic regression modelling was used to determine which sources were most strongly associated with being satisfied (or not satisfied), and to explore GP characteristics associated with satisfaction.

RESULTS

A total of 2186 questionnaires were returned, representing the opinions of 14-18% of Australian GPs. Two-thirds (68%) of respondents reported being satisfied, most frequently with the variety of work and establishing relationships with patients and their families. Six satisfaction factors were identified on factor analysis, the most important characterizing social and interpersonal roles. Leading sources of dissatisfaction related to perceived interference by the government. Six dissatisfaction factors were identified on factor analysis, the most important characterizing governmental issues. However, on logistic regression other sources of dissatisfaction (reflecting disillusionment) were most strongly associated with not being satisfied.

CONCLUSIONS

The main sources of satisfaction are those which typify the long-term caring role of the community GP. While the reform strategy aimed to address problems with the organization and financing of general practice, the resulting intervention is the focus of dissatisfaction. Among dissatisfied GPs these attitudes may arise primarily from a sense of disillusionment.

The surgical implications of purpura fulminans

Purpura fulminans is an uncommon catastrophic syndrome that occurs in children, typically one to four weeks after a seemingly benign infectious process. The child usually presents with a high fever, purpuric ecchymosis, hypotension, disseminated intravascular coagulation, and gangrene of the extremities. We have recently treated six children, whose mean age was 22 months; three were male and three were female. Five of the six had a change of mental status upon initial examination. Their mean temperature was 104 degrees F. All six children had purpuric involvement of their extremities; three had involvement of their hands, two had involvement of their faces, and two had involvement of their trunks. All had absent palpable pulses and sluggish capillary refill in the involved hands and feet. Two patients died shortly after admission as a result of severe end-stage sepsis. The platelet counts in these two patients, and the white blood cell counts were markedly depressed. The mean platelet count of the survivors was 370,000 and the mean white blood cell count was 25,000. Lumbar punctures were positive for bacterial meningitis in five patients and viral meningitis in one patient. All patients were treated with intravenous heparin. Of the four survivors, two lost significant tissue and required multiple plastic reconstructive procedures, and two improved on heparin alone with no tissue loss. In addition to systemic support and intravenous antibiotics, the mainstay of treatment is one of immediate heparinization and a continuous heparin drip. Heparin prevents subsequent small vessel thrombosis and limits tissue loss due to ongoing purpura. Conservative management of the purpuric lesions is the treatment of choice until final demarcation occurs.

Susceptibility to AIDS progression appears early in HIV infection

To investigate whether predictors of AIDS progression are operative very early in the natural history of HIV infection, we conducted a nested case-control study within a cohort of 119 subjects who seroconverted while under observation in a prospective study of homosexual men. For each of the 18 cases who have progressed to AIDS, we randomly selected three controls who had seroconverted within 3 months of the case but who have remained AIDS-free. Cases and controls were compared with regard to laboratory and clinical parameters obtained at the time of the earliest HIV-positive result. The median duration between the estimated date of seroconversion and this first positive result was 4 months for cases and 6 months for controls. Cases exhibited lower CD4 counts (657 versus 774 x 10(6)/l; P = 0.037), lower CD4: CD8 ratios (0.98 versus 1.39; P = 0.003), higher immune complex levels (C1q binding: 25 versus 15%; P = 0.002), lower hemaglobin concentrations (14.8 versus 15.2 g/l; P = 0.011), higher immunoglobulin (Ig) A levels (272 versus 184 mg/dl; P = 0.003), and higher IgG levels (1530 versus 1300 mg/dl; P = 0.037) than controls. Cases exhibited higher CD8 counts of marginal statistical significance (732 versus 597 x 10(6)/l; P = 0.059). No differences were observed with respect to IgM levels, total lymphocyte or white blood cell counts, or the frequency of generalized lymphadenopathy. A total of 27.8% of cases but only 11.5% of controls reported one or more symptoms during the 6-month period preceding the first positive visit (P = 0.027). We conclude that laboratory and clinical abnormalities which are predictive of more rapid progression to AIDS may appear very early in HIV infection. This suggests that some of the factors responsible for more rapid disease progression are present in the host prior to or shortly after infection occurs.

Obstructive airways disease in non-smoking subjects with pigeon fanciers' lung

The aim of the study was to assess the degree of airways involvement in non-smoking subjects with extrinsic allergic alveolitis resulting from pigeon-derived antigens. Two hundred and eight pigeon fanciers completed a questionnaire of symptoms, performed spirometry on a Vitalograph Compact spirometer and had IgG antibody to pigeon gamma-globulin measured. Eighty fanciers had the acute form of pigeon fanciers' lung (PFL) and these subjects were less likely to be current smokers (P less than 0.001). Subjects with PFL had a higher prevalence of chronic bronchitis (P less than 0.001), large airways (P = 0.014) and peripheral airways obstruction (P less than 0.001). The prevalence of chronic bronchitis and peripheral airways obstruction increased significantly as the level of antibody to pigeon gamma-globulin rose. Peripheral airways obstruction, as manifest by a reduced FEF25-75%, was the most common abnormality found. Airways disease is an important feature of the acute form of PFL and consists of a hypersecretory disorder in the form of chronic bronchitis and of obstructive airways disease particularly affecting the peripheral airways.

Progression to AIDS and predictors of AIDS in seroprevalent and seroincident cohorts of homosexual men

As part of an ongoing prospective study of seropositive homosexual men in Vancouver, Canada, a seroprevalent cohort of 246 subjects (i.e. duration of infection unknown) and a seroincident cohort of 102 subjects (i.e. duration of infection known) were followed a median of 63 and 45 months, respectively. Follow-up with validation utilizing record linkage with the Canadian Federal Centre for AIDS registry revealed 58 and nine cases of AIDS in the seroprevalent and seroincident cohorts, respectively, through July 1988. These data yield product limit estimates of the cumulative progression rates to AIDS at 60 months of 23.0% for the seroprevalent cohort, 13.0% for the seroincident cohort, and 21.0% for the combined groups. Univariate analyses revealed the following to be statistically and clinically significant predictors of AIDS progression: low CD4 counts, low CD4/CD8 ratios, elevated immune complexes, elevated immunoglobulin G (IgG) and immunoglobulin A (IgA) levels, and low platelet counts. Cox regression revealed that elevated IgA levels, low CD4 counts, elevated immune complexes, two or more symptoms, and more than 20 male sexual partners in high-risk areas in the 5 years prior to enrollment were independent predictors of progression to AIDS over the subsequent 5 years. A multivariate risk function based on the latter five variables delineated low-, medium- and high-risk groups whose 5-year progression rates to AIDS were 6.7, 15.6 and 64.4%, respectively. The high-risk group contained 75% of all subjects who progressed to AIDS. Only 6% of the high-risk group would have qualified for zidovudine therapy under current guidelines at the beginning of the observation period.(ABSTRACT TRUNCATED AT 250 WORDS)

Patterns of sexual behavior and condom use in a cohort of homosexual men

To measure the magnitude of risk reduction within a cohort of homosexual men, questionnaire responses in April 1984-March 1985 were compared to those in October 1986-September 1987. A total of 361 subjects were eligible (231 seronegative, 130 seropositive). The annual number of sex partners declined significantly from a median of 8.0 to 5.0 with no difference between the serologic groups. The number of subjects reporting no receptive anal intercourse increased as did condom use during anal receptive intercourse. More seronegatives than seropositives subjects reported no condom use during receptive anal intercourse with regular partners (45.7 per cent versus 23.4 per cent), and with casual partners (14.9 per cent versus 1.5% percent). Among subjects with the most casual sexual contact at the second visit, 33.3 per cent of seronegatives and 29.2 per cent of seropositives did not report usual condom use during receptive anal intercourse with casual partners. Although we have documented marked risk reductions, safe sex practices are still not universal, and a few individuals continue to put themselves at extremely high risk.

Proximal femoral resection to allow adults who have severe cerebral palsy to sit

Resection of the proximal end of the femur and interpositional arthroplasty was done in thirty-four patients (fifty-six hips) to allow the patients to sit comfortably and to make perineal care painless. All of the patients were severely handicapped because of cerebral palsy, were unable to walk, and were residents of one of two state institutions. After a minimum follow-up of two years, the result had not deteriorated in thirty-three of the thirty-four patients.

Ganglions of the temporomandibular joint: case report and review of literature

We present the third reported case of a ganglion cyst arising from the temporomandibular joint. Like the previous two cases, this lesion occurred in a woman over the age of 40. Unlike the lesions in previous reports, the cyst in our patient was not associated with pain or tenderness, making the diagnosis of parotid tumor more likely. Nevertheless, the case serves to illustrate the need for including ganglion in the differential diagnosis of well-encapsulated preauricular masses in the region of the temporomandibular joint.

The Vancouver Lymphadenopathy-AIDS Study: 7. Clinical and laboratory features of 87 cases of primary HIV infection

In an ongoing prospective study of homosexual men conducted in Vancouver since November 1982, 87 cases of human immunodeficiency virus (HIV) seroconversion have been documented to date. Comparison of laboratory results obtained a mean of 4.9 months before and 5.4 months after the estimated date of seroconversion revealed that a significant increase in the serum IgG level (from 1149 to 1335 mg/dl on average) and in C1q binding (from 8.8% to 14.2% on average) was associated with early HIV infection (p less than 0.001). A marginally significant decrease in the ratio of helper to suppressor (CD4 to CD8) cells (from 1.55 to 1.29 on average) was also noted (p = 0.025). A marked decrease in absolute number of CD4 cells was not seen with seroconversion, which suggests that profound loss of these cells may be a long-term effect of HIV infection. The occurrence of symptoms (including fatigue, fever, night sweats, unintentional weight loss, diarrhea, joint pains, cough unrelated to smoking, shortness of breath, oral thrush, herpes zoster and rash) did not increase with seroconversion. This finding suggests that most cases of HIV seroconversion may be asymptomatic or associated with relatively minor symptoms. On the other hand, generalized lymphadenopathy was found to develop after HIV seroconversion in about 50% of cases.

Effects of long-term seropositivity to human immunodeficiency virus in a cohort of homosexual men

The long-term effects of HIV infection were evaluated by comparing data from two visits a mean of 18 months apart in groups of 148 persistently seropositive and 287 persistently seronegative homosexual men. At each visit, the seropositive men exhibited lower CD4 counts, CD4/CD8 ratios, hemoglobin concentrations and lymphocyte counts, and higher C1q binding, IgG and IgA levels. More important, the decline of the CD4/CD8 ratio and the rise of the C1q binding, IgG and IgA, progressed significantly in the seropositive group between visits. Seropositive men were at elevated risk of developing constitutional symptoms and generalized lymphadenopathy. An association was present between development of symptoms and inversion of the CD4/CD8 ratio. The 11 seropositive men who have progressed to AIDS had lower CD4 counts and CD4/CD8 ratios, and higher C1q binding, IgG and IgA, than 134 seropositive AIDS-free men a mean of 21.4 months prior to diagnosis. The AIDS group demonstrated greater decline between visits in the CD4 count, hemoglobin and white blood count (WBC) than the seropositive AIDS-free group. The present data document the long-term effects of HIV infection in a seropositive cohort and suggest the possibility of a subgroup particularly susceptible to the progressive effects of HIV that precede the development of the acquired immunodeficiency syndrome (AIDS).

Beneficial effects of ibuprofen on experimental microvascular free flaps: pharmacologic alteration of the no-reflow phenomenon

Pharmacologic alteration of the no-reflow phenomenon was determined based on increased tolerance to ischemia in ibuprofen-treated free flaps. Sprague-Dawley rats (N = 60) were divided into control (lactated Ringer's) and treated (ibuprofen) groups and subdivided into six groups of ischemia: 1 hour, 6 hours, 8 hours, 10 hours, 12 hours, and 14 hours of ischemia. Fluorescein uptake was measured after 10, 30, and 60 minutes following microrevascularization. Dye elimination studies were done for each ischemia group that demonstrated good fluorescein uptake. All free flaps in the 1-, 6-, and 8-hour groups survived. The ibuprofen-treated 10- and 12-hour flaps all survived, whereas the 10-hour control and 14-hour ibuprofen-treated free flaps failed to survive. Despite high fluorescein uptake, the 14-hour ibuprofen-treated flaps did not eliminate the fluorescein, whereas all surviving free flaps adequately eliminated the fluorescein. Failure to eliminate dye despite adequate uptake suggested a deranged microcirculation with increasing ischemia time. By inhibiting cyclo-oxygenase, nonsteroidal anti-inflammatory agents such as ibuprofen may block the untoward effects mediated by thromboxane A2, such as vasoconstriction, microvasculature thrombus formation, and intravascular sludging. These effects are theorized in part to be responsible for the failure of a free flap to survive despite revascularization.

The Vancouver Lymphadenopathy-AIDS Study: 6. HIV seroconversion in a cohort of homosexual men

In an ongoing prospective study of homosexual men conducted since November 1982 in Vancouver, we identified 345 men who did not have antibody to human immunodeficiency virus (HIV) at the time of enrolment and for whom results of follow-up serologic testing were available. A total of 66 cases of seroconversion were documented among the 345 men between November 1982 and October 1985. Methods of survival data analysis that take into account the varying durations of follow-up were used to study the epidemiologic features of seroconversion in this group. The probability of seroconversion during the entire observation period was 23.1%. The seroconversion rates remained stable, at 10.5% and 10.0% during the last 2 years of the observation period. Cox regression analysis revealed the following variables to be independently associated with risk of seroconversion: frequent receptive anal intercourse, elevated number of male sexual partners in the year before enrolment, use of illicit drugs, a history of gonorrhea and age less than 30 years in November 1982. Multivariate analysis failed to reveal any role of oral sexual activity in the transmission of HIV. Oral ingestion of semen was not associated with seroconversion in either univariate or multivariate analysis. The observation that younger men were more likely to seroconvert suggests that young homosexual men were less likely than older men to modify their sexual behaviour.

Diagnostic utility of lymphocyte subset analysis in AIDS case finding

Abnormalities of lymphocyte subsets, especially low absolute number of helper T cells, are characteristically present in acquired immune deficiency syndrome (AIDS). Similar abnormalities can be found in patients with persistent generalized lymphadenopathy (PGL) or AIDS-related complex (ARC) and, to a lesser degree, in asymptomatic people who have been exposed to human T-lymphotropic virus type III (HTLV-III). Nevertheless, there appears to be a widespread perception that lymphocyte subset analysis may be useful in AIDS case finding within high-risk groups. We evaluated the diagnostic utility of absolute number of helper T cells and ratio of helper to suppressor T cells in 33 patients with AIDS, 43 patients with PGL who had been referred for lymph node biopsy, 90 patients with PGL and 195 male homosexual controls. At conventional cutoff levels the tests did not appear to revise the probability of AIDS upward to any clinically significant degree when the pretest probability of AIDS was low. Lymphocyte subset analysis does not appear to be a cost-effective method of AIDS case finding in identified groups at risk in which the prevalence of AIDS is low.

The Vancouver Lymphadenopathy-AIDS Study: 3. Relation of HTLV-III seropositivity, immune status and lymphadenopathy

In a study of 394 homosexual men recruited at the primary care level the prevalence of antibody to human T-lymphotropic retrovirus (HTLV-III) was higher among those with lymph node enlargement than among controls. The degree of abnormal immune function, as shown by abnormalities in immunoglobulin levels, immune complex activity and T-lymphocyte subsets, was correlated with the extent of lymphadenopathy. A similar pattern of immunologic abnormality was associated with seropositivity for HTLV-III antibody. However, HTLV-III seropositivity was the major determinant of immune function after adjustment for lymph node status. The results suggest that the immune dysfunction seen in patients with lymphadenopathy is due for the most part to the high prevalence of HTLV-III seropositivity in these populations. Lymphadenopathy, in many subjects, may in fact represent a physical sign of a stabilized compensated homeostatic host response. Factors responsible for severe immune decompensation associated with acquired immune deficiency syndrome (AIDS) may best be sought by prospective study of HTLV-III seropositive asymptomatic patients or those with stable persistent generalized lymphadenopathy and relatively normal immune function.

Enhancement of blood flow in experimental microvascular free flaps

Prolonged ischemia may result in tissue death because of the no-reflow phenomenon. By raising a flap 24 hours prior to subjecting it to ischemia, the authors have been able to significantly lengthen the ischemia interval prior to the onset of tissue death. These effects are believed to be the result of alteration of the no-reflow phenomenon.

Reactions of the Lythraceae alkaloids. Regio and stereoselective methoxylations and hydroxylations of lythrine

Mercuric acetate assisted methoxylations and hydroxylations of lythrine resulted in a regio and stereoselective introduction of the substituent at the benzylic position with S-stereochemistry. The compounds obtained are thus epimeric at C13 with the naturally hydroxylated alkaloid lythridine and its derivatives. The implications of the results in planning the total synthesis of lythrine is discussed.

Pelvic colonization with Actinomyces in women using intrauterine contraceptive devices

Recent reports suggest a relationship between intrauterine contraceptive device (IUD) use and colonization or infection of the genital tract with Actinomyces species. This prospective, case-controlled study was designed to determine the incidence of colonization or infection with Actinomyces in IUD users. None of 50 control patients and four of 50 study patients (8%) had Actinomyces identified. None of the patients with positive results had symptomatic pelvic infection. Cervical cytology was effective in detecting each of the four study patients with positive results. It appears that the presence of any type of IUD is a major predisposing factor to colonization with Actinomyces.

Black pigment stone in a male child aged two years and seven months

A case of cholelithiasis is reported occurring in a boy aged two years and seven months. The patient presented with biliary colic, and cholecystectomy was performed. Detailed analysis of the stone, including electron-probe studies, showed it to be an example of a polybilirubinate stone, containing also calcium, carbonate, and phosphate, with some sulphur, sodium, and magnesium. There were also traces of chlorine, aluminium, copper, nickel, and manganese.

Bacteroides: a cause of residual abscess?

Bacteroides fragilis as a cause of residual abscess has not been previously demonstrated. This clinical and bacteriologic study of 54 consecutive cases of appendectomy in children suggests that if B. fragilis is found in the peritoneal fluid at the time of operation there is a strong possibility of residual abscess development. Special collection and culture methods are necessary to obtain positive cultures of this strictly anaerobic organism.

Cimicine and Cimicidine, Lactonic Alkaloids from Haplophyton cimicidum

Evidence is presented in support of the stereostructures 4 and 5 for cimicine and cimicidine, respectively. Alkaloids 4 and 5, as well as the lactonic bases aspidophytine (23) and haplophytine (1), are converted by alkaline hydrogen peroxide to the corresponding 10-oxo derivatives.